The death of a schizophrenic man in police custody is a symptom of a deeper problem with half of the deaths in police custody last year involving people with mental illness, the police watchdog warned today.
Sean Rigg's condition was deteriorating before his arrest, but he was not subject to a mental health risk assessment and officers did not respond to or recognise his condition, the Independent Police Complaints Commission (IPCC) said.
An inquest jury found earlier this month that the officers used "unsuitable" force after arresting Rigg for attacking passers-by and police officers in Balham, south London, on August 21, 2008.
The physically fit 40-year-old musician was being held at Brixton police station when he died of cardiac arrest, Inner London South Coroner's Court heard.
Amerdeep Somal, who carried out the IPCC's report said: "Sean Rigg's death is a symptom of a deeper problem: the linkage between mental illness and deaths in or following police custody.
"At the inquest, concerns were raised about the care Mr Rigg received from the South London and Maudsley Mental Health Trust (Slam).
"It is clear that, although staff at the supported hostel where he was living recognised that his condition was deteriorating during August and that his medication was overdue, he was not subject to a mental health risk assessment by staff at Slam.
"Nor did the police involved recognise or respond to his condition."
IPCC chairwoman Dame Anne Owers will be commissioning an external review of the IPCC's own investigation, which will help the overall review of deaths following police contact which is due to start in September, the watchdog added.
Half of all deaths in police custody in 2011/12 were of people with mental illness, Ms Somal said in her foreword to the report.
"They represent a particularly vulnerable group, often, as in Mr Rigg's case, failed by the people and systems that ought to protect them," she said.
"As the IPCC has repeatedly stated, police stations are not, and cannot be, a 'place of safety' for people with mental health problems."
Ms Somal went on: "In relation to the action or inaction of police officers, further evidence has emerged through the inquest process, which the IPCC is now considering.
"What is clear, though, is that there was a series of missed opportunities - involving both health and police services - which, if taken, might have altered the outcome.
"I have no doubt there are lessons for the IPCC from the investigation into Mr Rigg's tragic death."
Mr Rigg's family welcomed the review of the IPCC investigation.
In a statement, they said: "There has never been any doubt in our minds that the IPCC's inadequate report of February 2010 reflected an extremely poor and ineffective investigation into Sean's death.
"For the IPCC to conclude in their findings that 'the officers adhered to policy and good practice by monitoring Mr Rigg in the back of the van' is absolutely absurd, flies in the face of the evidence and clearly contradicts the jury's narrative verdict.
"The family therefore welcome an external review of the IPCC's original investigation by someone that is truly independent.
"However, we absolutely insist that the review is a root-and- branch examination of the IPCC's investigation and that it is transparent, robust and effective, so that officers are made accountable for Sean's death."
Helen Shaw, co-director of campaign group Inquest, said: "The contrast between the highly critical inquest jury verdict and the two insubstantial findings of the IPCC report could not be clearer.
"It should not have taken an inquest to discover some basic facts, such as the restraint of Sean Rigg in the prone position lasting several minutes, rather than seconds according to officer accounts which were accepted by the IPCC.
"It is a clear indication of the wider systemic problems with the poor quality of too many IPCC investigations into deaths in custody.
"It is vitally important that both the external review of this investigation and the long-awaited review of their whole approach to such investigations marks a sea change.
"Families should not have to rely on their own efforts to make sure the full facts about such deaths are established and those responsible for deaths are held to account."
